Recent changes in Indiana's HIV-prevention funding policy, calling for the removal of gay white males from the priority population recommendations, have left some in the LGBT community feeling that a large number of at-risk people will be unprotected under the new plan.
The decision was reached on April 21, when Indiana's HIV-prevention community planning group held a meeting to discuss issues facing people affected by or in danger of contracting HIV/AIDS. Central to this discussion was the list of populations to be targeted by the Indiana State Department of Health as being of highest priority in administering funding to HIV-prevention programs.
The planning group decided to eliminate white MSM (men having sex with men) from their list of funding priorities. It is a change that surprises a number in the LGBT community, with some fearing major repercussions in the white MSM population. The removal has caused all parties of the debate to look at the role the community planning group plays in HIV prevention.
Ultimately, it is the ISDH that allocates money to HIV-prevention groups, first by administering the Request for Proposals process and then by choosing the groups that will receive federal funding. The community planning group's job is to set forth a series of recommendations for what are called the "priority populations," those groups considered most in need of funding. While the ISDH is not legally required to follow these recommendations, the planning group's priorities largely dictate funding parameters.
The Centers for Disease Control and Prevention mandates that people currently living with HIV/AIDS are always to be the top priority. In Indiana, the second priority group has included MSM, subgrouped into white, African-American and Hispanic. With the new recommendations, only African-American and Hispanic MSM are included in the "second priority group."
The philosophy behind the change is to allocate a greater amount of resources to the communities in greatest need. Determining the need, however, has led to debate over whether or not the new priorities demonstrate a disproportionate funding policy, or if it simply reflects the changing realities in the way HIV infections affect members of the community.
For many, the heart of the issue lies in the relation between two terms used to chart HIV/AIDS cases: prevalence and incidence. Prevalence, as defined by the CDC, refers to "the number of people living with HIV/AIDS in a specific area during a specific time period." Incidence measures the "number of people newly infected with HIV in a specific area during a specific time period."
When information from the ISDH's 2008 Epidemiology Profile is examined from each of these perspectives, very different implications emerge regarding how HIV/AIDS affects target populations.
On a total number basis in Indiana, HIV/AIDS cases in the white MSM population make up 56.8 percent of those living with the disease, with African-American and Hispanic MSM numbering 34.5 and 6.6 percent, respectively.
On the surface, these numbers seem to suggest that white MSM are a considerably more at-risk group. However, the Epidemiology Profile also shows that, per capita, the incidence rates were highest among African-Americans at 37.1 per 100,000, followed by Hispanics at 14.3 per 100,000. Meanwhile, the incidence rates for whites are considerably lower at 4.2 per 100,000.
"The priority populations reflect populations that have shown a higher increase in infection rates. Therefore, the [community planning group] feels that these demographics warrant a heightened focus," says ISDH media relations coordinator Ken Severson, in an e-mailed statement. He reiterates that people currently living with HIV/AIDS -- including all MSM -- are always the community planning group's top priority, but that prevention programs need to follow recent rates of infection.
Some disagree, however, including those in the local LGBT community.
"The CDC guidelines, in several instances, fairly explicitly direct community planning groups to [include] both the incidence and prevalence of target populations in establishing the community's priorities," says Gary Essary, board spokesperson for the Tri-State Alliance, a Midwestern LGBT organization. In this case, the community planning group "has chosen to go entirely with incidence in establishing its priorities."
Essary worries that the policy change on the part of the planning group could cause serious problems for the white MSM population, including even a spike in HIV/AIDS prevalence. However, some policy experts say that the CDC actually gives the community planning group a good deal of discretion.
Dr. Eric Wright, director of Indiana University's Center for Health Policy and an expert on HIV prevention, notes that the CDC "[doesn't] dictate the criteria on which decisions are to be made. They dictate more how the structure of the groups should be created to make divisions about that process."
While the decision was made more than three months ago, last Tuesday's community planning group meeting yielded no concrete changes in the subject. It did, however, offer an interesting look into the meeting's process. While the group's members showed mutual respect, the meeting was fraught with factionalism, with some members seeming to be primarily focused on the interests of the groups they represent.
At one point, an otherwise quiet representative was forced to chastise the members, attempting to coax them towards a common goal rather than in-fighting. "We can't keep doing this," he said.
Perhaps it is useful then that the community planning group's Epidemiology Populations Committee handout stated that they were "extremely concerned that the [community planning group] must carry out a logical, evidence-based process to determine the highest priority ... that the [community planning group] could not make decisions based on emotion and anecdotal information in determining priority populations as in previous years."
It's easy to see how a debate over HIV/AIDS funding could become emotional. What on the surface may seem like a minor change in policy could potentially have sweeping ramifications in HIV prevention and treatment in Indianapolis and it remains to be seen what kind of influence such a change of policy could have on the community.
"I don't think it will affect the services we provide," says Kerrie Kikendall, interim director of prevention programs and testing services at the Damien Center. "We'll continue to serve whoever walks in our door and needs prevention services."
She notes that service organizations typically receive funding from a number of sources, not just the ISDH. While there is still quite a bit of confusion about the decision, Kikendall feels things won't change much yet.
"It's kind of crazy what happened with the [community planning group], but at the same time I don't really feel like the Indiana State Department of Health is going to let the white MSM slip from their priority populations."